<html><head>

        <title>Formulir Data Penduduk</title> 
        <link href="<?php echo base_url('assets/css/formpenduduk.css'); ?>" rel="stylesheet" type="text/css" />
        <link href="<?php echo base_url('assets/js/jquery-ui.css'); ?>" rel="stylesheet" type="text/css" />
        <script type="text/javascript" src="<?php echo base_url('assets/js/jquery-1.9.1.js'); ?>"></script>
        <script type="text/javascript" src="<?php echo base_url('assets/js/jquery-ui.js'); ?>"></script>

        <style type="text/css">
            <!--
            .style1 {color: #F0F0F0}
            .style2 {font-size: 24px}
            -->
        </style>
        <script type="text/javascript">
            $(function() {
                $("#tgl_lahir").datepicker({changeMonth: true, changeYear: true});
				$("#tgl_suratnikah").datepicker({changeMonth: true, changeYear: true});
				$("#tgl_suratcerai").datepicker({changeMonth: true, changeYear: true});
            });
        </script>
    </head>
    <body>
        <form action="<?php echo base_url('penduduk/tambah'); ?>" method="post">
            <table width="715" border="0" align="center">
                <tr>
                    <td colspan="8" class="trheader"><strong>Formulir Data Penduduk</strong></td>
                </tr>
                <tr>
                    <td colspan="8" class="jeda"><strong>Data Personal Penduduk </strong></td>
                </tr>
                <tr>
                    <td width="122">NIK</td>
                    <td colspan="3"><input type="text" name="nik" id="nik" class="textinput" placeholder="3501061411910002" value=""/></td>
                    <td width="5">&nbsp;</td>
                    <td width="147">Nama</td>
                    <td colspan="2"><input type="text" name="nama" id="nama" class="textinput" placeholder="Niken Larasati" /></td>
                </tr>
                <tr>
                    <td>Tempat Lahir</td>
                    <td colspan="3"><input type="text" name="tempat_lahir" id="tempat_lahir" class="textinput" placeholder="Pacitan"/></td>
                    <td>&nbsp;</td>
                    <td>Tanggal Lahir</td>
                    <td colspan="2">&nbsp;&nbsp;&nbsp;<input type="text" name="tgl_lahir" id="tgl_lahir" /></td>
                </tr>
                <tr>
                    <td>Jenis Kelamin</td>
                    <td colspan="3">
                        <input name="idjenis_kelamin" type="radio" class="radiobutton" id="1" value="1" checked />
                      Laki-laki
                        <input name="idjenis_kelamin" type="radio" value="2" id="2" class="radiobutton" />Perempuan</td>
                    <td>&nbsp;</td>
                    <td>&nbsp;</td>
                    <td colspan="2">&nbsp;</td>
                </tr>
                <tr>
                    <td>Pendidikan Akhir</td>
                    <td colspan="3"><select name="idpendidikan" class="list">
                			<?php
                            if (isset($pendidikan)){
							foreach ($pendidikan->result() as $data_pendidikan){
                            echo '<option value="'.$data_pendidikan->idpendidikan.'">'.$data_pendidikan->pendidikan.'</option>';
							}
                            }
							?>
                        </select></td>
                    <td>&nbsp;</td>
                    <td>Golongan darah</td>
                    <td colspan="2"><select name="idgol_darah" id="idgol_darah" class="list">
                      <option value="1">A</option>
                      <option value="2">B</option>
                      <option value="3">AB</option>
                      <option value="4">O</option>
                      <option value="5">-</option>
                    </select></td>
                </tr>
                <tr>
                    <td>Agama</td>
                    <td colspan="3"><select name="idagama" id="idagama" class="list">
                <option value="1" selected>Islam</option>
                            <option value="2">Kristen Katolik</option>
                            <option value="3">Kristen Protestan</option>
                            <option value="4">Hindu</option>
                            <option value="5">Budha</option>
                            <option value="6">Konghuchu</option>
                            <option value="7">Kepercayaan</option>
                        </select></td>
                    <td>&nbsp;</td>
                    <td>Pekerjaan</td>
                    <td colspan="2"><select name="idpekerjaan" id="idpekerjaan" class="list">
                      <option value="1">Belum/Tidak Bekerja</option>
                      <option value="2">Mengurus Rumah Tangga</option>
                      <option value="3">Pelajar/Mahasiswa</option>
                      <option value="4">Pensiunan</option>
                      <option value="5">Pegawai Negeri Sipil</option>
                      <option value="6">Tentara Nasional Indonesia</option>
                    </select></td>
                </tr>
                <tr>
                  <td>Kewarganegaraan</td>
                  <td colspan="3"><select name="idkewarganegaraan" id="idkewarganegaraan" class="list">
                    <option value="2">WNI</option>
                    <option value="3">WNA</option>
                  </select></td>
                  <td>&nbsp;</td>
                  <td>Keturunan</td>
                  <td colspan="2"><input type="text" name="keturunan" id="keturunan" class="textinput" /></td>
                </tr>
                <tr>
                    <td>Status Perkawinan</td>
                    <td colspan="3"><select name="idstatus_kawin" id="idstatus_kawin" class="list">
                            <option value="2">Belum Kawin</option>
                            <option value="3">Kawin</option>
                            <option value="4">Cerai Hidup</option>
                            <option value="5">Cerai Mati</option>
                        </select></td>
                    <td>&nbsp;</td>
                    <td> Status dalam Keluarga</td>
                    <td colspan="2"><select name="idstatus_keluarga" class="list" id="idstatus_keluarga">
                            <option value="2">Kepala Keluarga</option>
                            <option value="3">Suami</option>
                            <option value="4">Istri</option>
                            <option value="5">Anak</option>
                            <option value="6">Menantu</option>
                            <option value="7">Cucu</option>
                        </select></td>
                </tr>
                <tr>
                    <td>Status Menetap</td>
                    <td colspan="3">
                        <input name="status" type="radio" value="1" id="A" class="radiobutton" />Aktif
                        <input name="status" type="radio" value="0" id="N" class="radiobutton" />Non-Aktif                    </td>
                    <td>&nbsp;</td>
                    <td>Telp</td>
                    <td colspan="2"><input type="text" name="telp" id="telp" class="textinput" placeholder="089761976713"/></td>
                </tr>
                <tr>
                    <td>Nama Ayah</td>
                    <td colspan="3"><input type="text" name="nama_ayah" id="nama_ayah" class="textinput" placeholder="Supeni"/></td>
                    <td>&nbsp;</td>
                    <td>Nama Ibu</td>
                    <td colspan="2"><input type="text" name="nama_ibu" id="nama_ibu" class="textinput" placeholder="Sumarni"/></td>
                </tr>
                <tr>
                    <td colspan="8">&nbsp;</td>
                </tr>
                <tr>
                    <td colspan="8" class="jeda"><strong>Data Dokumen Penduduk</strong></td>
                </tr>
                <tr>
                    <td>No. Kartu Keluarga</td>
                    <td colspan="3"><input type="text" name="no_kk" id="no_kk" class="textinput" placeholder="3501062001053536"/></td>
                    <td>&nbsp;</td>
                    <td>No. Surat Nikah</td>
                    <td colspan="2"><input type="text" name="no_suratnikah" id="no_suratnikah" class="textinput" placeholder=""/></td>
                </tr>
                <tr>
                    <td>&nbsp;</td>
                    <td colspan="3">&nbsp;&nbsp;&nbsp;<input type="button" name="carikk" id="carikk" value="Cari Data KK" class="radiobutton-kiri"/></td>
                    <td>&nbsp;</td>
                    <td>Tanggal Nikah</td>
                    <td colspan="2"><input type="text" name="tgl_suratnikah" id="tgl_suratnikah" class="textinput" placeholder=""/></td>
                </tr>
                <tr>
                    <td>No. Paspor</td>
                    <td colspan="3"><input type="text" name="no_passpor" id="no_passpor" class="textinput" placeholder=""/></td>
                    <td>&nbsp;</td>
                    <td>No. Surat Cerai</td>
                    <td colspan="2"><input type="text" name="no_suratcerai" id="no_suratcerai" class="textinput" placeholder=""/></td>
                </tr>
                <tr>
                    <td>No. Kitas</td>
                    <td colspan="3"><input type="text" name="no_kitas" id="no_kitas" class="textinput" placeholder=""/></td>
                    <td>&nbsp;</td>
                    <td>Tanggal Cerai</td>
                    <td colspan="2"><input type="text" name="tgl_suratcerai" id="tgl_suratcerai" class="textinput" placeholder=""/></td>
                </tr>
                <tr>
                    <td colspan="8">&nbsp;</td>
                </tr>
                <tr>
                    <td colspan="8"><input type="submit" name="tambah" id="tambah" value="Tambah" class="radiobutton-kiri"/>                      <input type="submit" name="lihat" id="lihat" value="Lihat Data" class="radiobutton-kiri" /></td>
                </tr>
            </table>
    </form>
    </body>
</html>
